NWRB-WUD-10-r1

APPLICATION FOR
Republic of the Philippines RENEWAL OF
NATIONAL WATER RESOURCES BOARD CERTIFICATE OF PUBLIC CONVENIENCE
8th Floor NIA Building, EDSA, Quezon City
Telefax (02) 920-2714
Water Utility (WU) Case Number
Accomplish this form in six (6) copies. Category1
Attach separate sheet if more space is required.
Name of Applicant Mailing Address Email Address

Contact No.

Citizenship TIN Year Operations Started

Provisional Authority Required? Filing Fee Amount OR No. Date Paid
 Yes  No
Location of Service Area
Subdivision

Barangay

Municipality
Province
Type of Utility Number of Connections Kind of Water System
 Subdivision / Homeowners’ Association With water meters ___________  Draw and Fill
 Rural Waterworks and Sanitation Without water meters ___________  Float
Association Meters tested?  Direct Pumping
 Cooperative  Yes  No For Bulk Water Seller/Peddler,
 Bulk Water Seller / Peddler If tested, Average volume of water delivered per day
 Others, specify: Tested by _________________ (in cu. m.)
Date tested _________________
Water Permit Information
Latitude Longitude
CWP/ Water Permit No. Source Barangay Location of Source
Deg. Min. Sec. Deg. Min. Sec.

See back page for applicable documentary requirements.

I hereby certify that the information given above and the documents Subscribed and sworn to before me on this date:
submitted are true and correct to the best of my knowledge and belief.

____________________________________________________ ______________________________________ _____________

Signature over printer name of Water Utility Representative
1 How
Category A
Water utilities operating for profit:
1. Privately-owned or privately run WUs; or
2. Government-owned and government-run WUs
that opted to be classified or NWRB has classified
it as Category A; or
3. Community based WUs that:
a) Have expanded/ are expanding outside
original area of jurisdiction, or
b) Opted to be classified or NWRB has classified
it as Category A
Notary Public / Administering Officer
to Determine the Water Utility Category
Category B
Government-owned and government-
run WUs that do not opt to be classified
as Category “A” or NWRB has classified
as Category B
Date
Category C
Community based WUs that:
1. Are not operating for profit;
2. Have not expanded/ are not
expanding outside their original area
of jurisdiction; or
3. Do not opt to be classified as
Category “A”/”B” or NWRB has
classified as Category “C”
 National Water Resources Board
APPLICATION FOR RENEWAL OF
CERTIFICATE OF PUBLIC CONVENIENCE

Name of Applicant Water Utility Category Case Number

Cat. Cat. Cat.

Documentary Requirements
A B C
1 Articles of Incorporation/Partnership or DTI Registration   
Authorization of signatory to sign and file the application
2  Board Resolution for corporations and partnerships, or   
 Special Power of Attorney for single proprietorship
3 Copy of approved Conditional / Water Permits   
4 Copy of official receipts of Annual Water Charges   
5 Copy of official receipts of Supervision and Regulation Fee   
Copy of latest Certificate of Potability
issued by the City/ Municipal Health Officer where the source is located,
6
with results of bacteriological, physical and chemical impurities
  
conducted by a Department of Health accredited laboratory
7 Plan of water distribution system   
8 Plan, elevation of cross-sectional views of tank/ reservoir   
9 Plan, elevation of cross-sectional views of pump house, machinery and equipment   
10 Copy of latest Annual Report   
11 Latest audited financial statements   
12 Simplified Financial Projections Model for Category C, or

Simple computation showing:

 Revenue requirements for one year, composed of:
o Operating expenses, with breakdown
  
o Depreciation
o Loan amortization (interest and principal) due
 Divided by volume sold for one year
13 Actual Balance Sheet for Water Operations   
14 Actual Income Statement for Water Operations   
15 Tariff schedule to be implemented   
16 Copy of CPC Certificate   
17 Others   